ACE Inhibitor as Effective as More Expensive Blood Pressure Drug

MONDAY March 31, 2008 -- Treatment with an ACE inhibitor drug was as effective in reducing deaths, heart attacks and stroke in a high-risk group of patients as a newer and more expensive angiotensin-receptor blocker (ARB) drug, a large international study has found.

The study of more than 17,000 people with coronary artery disease or diabetes found no major differences between those treated with the widely used ACE inhibitor ramipril (Altace) and those given the ARB telmisartan (Micardis).

"This is the first study in such a population that shows ACE inhibitors are as effective as ARBs," said study leader Dr. Salim Yusuf, a professor of medicine at McMaster University, in Hamilton, Ontario, Canada.

The finding might reduce the use of ARBs for such high-risk people, he said. "Even before the trial, many physicians have used ACE inhibitors as a first choice," Yusuf said. "I believe it will have an impact on practice."

The findings were to be presented Monday at the American College of Cardiology annual meeting in Chicago, and will be published in the April 10 issue of the New England Journal of Medicine.

Both classes of drugs are prescribed to lower blood pressure. But they act in different ways to block the activity of angiotensin, a molecule that narrows blood vessels.

"The main value of ARBs as monotherapy in patients with cardiovascular disease is, in my opinion, as a substitute for an ACE inhibitor in a patient who cannot tolerate the ACE inhibitor because of cough," said Dr. John J.V. McMurray, a professor of medical cardiology at the University of Glasgow in Scotland, who wrote an editorial accompanying the journal report.

"ACE inhibitors have never been tested in an outcome study in this patient population, and an ACE inhibitor and ARB have never been compared in this patient population," McMurray noted.

During a median follow-up time of 56 months, the incidence of deaths and adverse events was almost identical in the two groups -- 16.5 percent for those taking ramipril and 16.7 percent in the telmisartan group. It was also about the same in a group prescribed both medications, 16.3 percent, but there was a higher incidence of side effects such as abnormally low blood pressure and kidney problems among those taking the combination drug therapy.

ARBs still have a place in treatment of high-risk people such as those in the study, Yusuf said. "About 20 to 30 percent of people who take ACE inhibitors have side effects that make them stop," he said. The most common side effect is cough.

"On the other hand, ARBs seem to be valuable when added to an ACE inhibitor in patients with heart failure," McMurray said. The new study group did not include people with heart failure.

Switching from an ARB to an ACE inhibitor can reduce the cost of medical care, Yusuf said. Pill for pill, the cost of an ARB is about 20 percent higher than for an ACE inhibitor in Canada, he said.

More information

Learn more about ACE inhibitors, ARBs and other drugs for high blood pressure from the American Heart Association.

Posted: March 2008


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